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t souwcea STATE OF CALIFORNIA :P" ' °O r STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B •C�l1IOw M'' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: v— -5 5 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# B. MANUFACTURED BY: c� C. DATE INSTALLED(MO/DAYNEAR) 71 D. TANK CAPACITY IN GALLONS: / 0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑X1c MIDGRADE UNLEADED ❑ 5 JET FUEL F—] 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF1 DOUBLE WALL F—] 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM F-195 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ i BARE STEEL ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BtC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P555VENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES 1G NO STRIKER PLATE YES / NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A jg 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AU 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECHANICAL UNE LEAK 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE 5 AUTOMATIC PUMP DETECTOR 1:1 TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION GROUNDWANUAL ❑ 1 VISUAL CHECK 2 RECONCILMANUAL IJATIONVENTORY ❑ 3 MONITORING 4 GAUGINGAUTOMATIC TANK ❑5 MON TORINGTER ❑6 TESTINGTANK 7 CONTINUOUS% MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL ❑10 MONTHLY TANK E] 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? ^ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY AND TO TH EST OF MY KNOWLEDGE,IS TRUEANP CORRECT T,M(PRA 6&SIGN S NAME DATE (PR�b SIGNATURE) O LOCAL AGENCY USE ONLY THE STA�. NUBER IS COMPOSED OF THE FOUR NUMBERS BELOW COU JURISDICTION# FACILITY# TANK# STATE I.Dl m FM 2 j 1�5 Z PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPL N-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THOWRGROUND STORAGE TANK REGULATIONS FORMS (6-95)